
16 Chapter 1: The Approach of the Thesis The beginning of wisdom is found in doubting; by doubting we come to the question, and by seeking we may come upon the truth. ‒Pierre Abelard The problem explored and analysed in this study involves the experiences of five registered nurses and one enrolled nurse who were labelled whistleblower nurses by the Australian media. The participants of this study were all employees of the public health system in New South Wales, Australia. The person identified as ‘Kathrine’ is the researcher and author of this study, as well as a participant observer. Theoretical Framework To explore and understand the experiences of the participants of this study, a qualitative methodology was implemented using in-depth interviews. The participants, within a symbolic interactionist framework, were encouraged to explain how their experiences as nurses had led them to be labelled by the media and regarded by their colleagues as whistleblowers. This qualitative inquiry explores what it is to be a nurse, the concept of patient advocacy, the effects of bullying and harassment and the concept that qualities inherent in professional nurses underpin the compulsion for nurses to speak 17 out publicly. An attempt is also made to offer a professional definition of that which in other roles would be defined as whistleblowing. To undertake research about nursing and whistleblowing, it is necessary to explore how nurses work and why they behave as they do. For the research to reflect that which truly represents nursing, it is essential to acknowledge the existing social, cultural and political imperatives that have historically underpinned the profession. From this knowledge an appropriate qualitative research framework and methodology can be constructed. Stubblefield and Murray (2002), in support of this approach, warn there may be a flaw in qualitative studies if the method applied to the study is not linked or guided by the philosophical underpinnings of the research group. Nursing is described by Lopez and Willis (2004) as an art and a science that concerns itself with human interaction and specialised knowledge that has been drawn from lived experience, contextual realities and concern for those to whom they offer care. It would seem the most appropriate nursing research methods are, as described by Greene and Caracelli (1997), dialectical – that is, adopting a methodology to arrive at the truth by the exchange of logical arguments. This point of view embraces the premise that philosophical differences in human inquiry are real and, while sometimes not easily reconciled (Shaw, 2003), they represent the inherent differences and contradictions humans express in their everyday lives. 18 The acceptance of human interaction and its associated meanings guides the researcher towards a balanced reciprocal relationship between philosophy and methodology, between paradigm and practice. This ... honours both the integrity of the paradigm construct and the legitimacy of contextual demands and seeks a respectful, dialogical interaction between the two in guiding and shaping evaluation decisions in the field. (Greene & Caracelli, 1997, p. 17) Interpretive theories such as phenomenology and symbolic interactionism are well suited to nursing research for they promote ‘understanding unique individuals and their meanings and interactions with others and the environment’ (Meleis, 1996, p. 2). Specifically, according to van Manen (1990), phenomenology promotes borrowing human experience to promote understanding of human interactions and behaviours for the researcher. McConnell-Henry, Chapman and Francis (2009b) confirm the application of phenomenological inquiry is appropriate where human experience is central to the research question. History and the literature confirm there have been considerable phenomenological approaches to the study of nursing. Examples include Grover (1996), Robertson-Malt (1999), J. Madison and Minichiello (2000), Crist and Tanner (2003), Lopez and Willis (2004), McConnell-Henry, Chapman and Francis (2009a) and Garrett, Chan, Brykczynski, Malone and Benner (2010). 19 The term symbolic interactionism was credited in 1934 to George Herbert Mead; in 1969, it was developed by Herbert George Blumer, a student of Mead’s, to offer perspective to the way in which humans conduct their daily lives in conjunction with others (Shaw, 2003). Van Manen (1990) cited Blumer who declared symbolic interactionism to be underpinned by three core principles. First is meaning: ‘humans act towards things on the basis of the meanings they ascribe to those things’. Second is language: ‘the meaning of such things is derived from, or arises out of, the social interaction one has with others and the society’. Third is thought: ‘these meanings are handled in, and modified through, an interpretive process used by the person in dealing with the things he/she encounters’ (p. 2). Merton (1995) cited Thomas and Thomas (1928) who famously asserted ‘If men define situations as real, they are real in their consequences’ (p. 572). In other words, the interpretation of the context of the situation pre-empts individual reaction which is the result of subjective perception(s) of the situation. Symbolic interactionism theory argues humans are social beings, and as such are inseparable from the society in which they exist. According to Meltzer, Petras and Reynolds (1975), human behaviour is not determined by instinct, but rather by reflective, socially-driven interpretation of life experiences. Charon (2007), in support of this statement, says human objective reality is created out of social reality – the reality that is learned from others and their common surroundings. 20 The theory of symbolic interactionism is an appropriate framework to apply to the way nurses learn, work and socialise as a group. Nursing education in developed countries is offered via tertiary facilities with degree status awarded to successful candidates. Benner (1994), in her landmark study, describes how nursing students, through exposure to nursing culture, develop ‘nursing connoisseurship’ – a trait developed by the acquisition of expertise. Benner contends nursing students learn to recognise and describe ‘the context of meanings, characteristics and outcomes of their connoisseurship’ (p. 5). Nursing students learn about nursing culture and clinical practice from exposure to other nurses and actual clinical experience. The learning experience of nurses is, adds Holland (1999), a stepped process with rites of passage – ‘separation, transition and incorporation’ (p. 229). As nurses progress from students to neophytes to skilled clinicians, they migrate from the periphery of nursing practice to the central margins of nursing culture. Postgraduate nurses must learn to perform as clinicians within the defined clinical culture of the health care system if they are to be accepted into the dominant nursing culture of the employing organisation. Farrell (2001), in support of this argument, confirms nursing culture precipitates horizontal and vertical violence and poor colleague relationships. It was also stated ‘junior nurses are quickly socialised into a culture of nurse-to-nurse abuse’ (p. 28). This behaviour serves to validate the nursing 21 hierarchy and promote the status quo. Successful negotiation of the rites of passage and espousal of behaviours to act like a nurse seem pivotal if the new graduate is to be accepted into the wider nursing social group. Failure to adopt the values and attitudes of more senior nurses promotes isolation and ‘social limbo’ for neophytes (Grover, 1996, p. 56). Duffy, McCallum, Ness and Price (2012) concurred that the need to fit into the social nursing group can be to the detriment of the neophyte. Where a workplace has an absence of role models who report poor practice, it is unlikely the neophyte will act outside of the group norm. Nurses define their culture by their attitudes and their actions. There are boundaries that are tacitly accepted in the nursing profession. Whistleblower nurses, regardless of their intentions to protect their patients, by virtue of making public declarations of concern about patient care or safety violate nursing cultural norms and boundaries. Their actions, whether of advocacy or moral principle, attract criticism from the nursing profession; the whistleblower is then marginalised and treated as a professional pariah (Rosen, Katz, & Morahan, 2007). A great deal has been written about the experiences of nurses who have spoken out publicly regarding matters of professional conscience (Faunce, Bolsin, & Chan, 2004), patient advocacy (Chafey, Rhea, Shannon, & Spencer, 1998), perceived poor or adverse patient outcomes (Mesmer- Magnus & Viswesvaran, 2005) and ethical decision-making (Ahern & 22 McDonald, 2002). Berry (2004) aptly defines whistleblowing as ‘an avenue for maintaining integrity by speaking one’s truth about what is right and what is wrong. It is a strategy for asserting rights, protecting interests, influencing justice and righting wrongs’ (p. 1). This study adds to that body of literature. It describes the work context, experience and roles each nurse held at the time of the whistleblowing incident. There is an attempt to define and understand the nurses’ individual belief systems and align these beliefs with the reasons behind why each participant felt compelled to speak publicly. This study also attempts to capture the reasons why six experienced nurses, despite the consequences, chose to speak out
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